Báo cáo y học: "Predictors for good functional outcome after neurocritical care" docx

RESEARC H Open Access Predictors for good functional outcome after neurocritical care Ines C Kiphuth 1* , Peter D Schellinger 1 , Martin Köhrmann 1 , Jürgen Bardutzky 1 , Hannes Lücking 2 , Stephan Kloska 2 , Stefan Schwab 1 , Hagen B Huttner 1 Abstract Introduction: There are only limited data on the long-term outcome of patients receiving specialized neurocritical care. In this study we analyzed survival, long-term mortality and functional outcome after neurocritical care and determined predictors for good functional outcome. Methods: We retrospectively investigated 796 consecutive patients admitted to a non-surgical neurologic intensive care unit over a period of two years (2006 and 2007). Demographic and clinical parameters were analyzed. Depending on the diagnosis, we grouped patients according to their diseases (cerebral ischemia, intracranial hemorrhage (ICH), subarachnoid hemorrhage (SAH), meningitis/encephalitis, epilepsy, Guillain-Barré syndrome (GBS) and myasthenia gravis (MG), neurodegenerative diseases and encephalopathy, cerebral neoplasm and intoxication). Clinical parameters, mortality and functional outcome of all treated patients were analyzed. Functional outcome (using the modified Rankin Scale, mRS) one year after discharge was assessed by a mailed questionnaire or telephone interview. Outcome was dichotomized into good (mRS ≤ 2) and poor (mRS ≥ 3). Logistic regression analyses were calculated to determine independent predictors for good functional outcome. Results: Overall in-hospital mortality amounted to 22.5% of all patients, and a good long-term functional outcome was achieved in 28.4%. The parameters age, length of ventilation (LOV), admission diagnosis of ICH, GBS/MG, and inoperable cerebral neoplasm as well as Therapeutic Intervention Scoring System (TISS) -28 on Day 1 were independently associated with functional outcome after one year. Conclusions: This investigation revealed that age, LOV and TISS-28 on Day 1 were strongly predictive for the outcome. The diagnoses of hemorrhagic stroke and cerebral neoplasm leading to neurocritical care predispose for functional dependence or death, whereas patients with GBS and MG are more likely to recover after neurocritical care. Introduction Within the last decades, specialized neurocritical inten- sive care units (NICU) have evolved from bigger, multi- disciplinary ICUs [1]. This specialization has led to a decrease in both in-hospital mortality and length of hos- pital stay without associated effects on re admission rates and long-term mortality [2]. Nevertheless, case fatality of patients admitted t o NICUs is still high and the out- come often poor [3]. Yet, there are still little data on clinical parameters associated with long-term outcome after neurocritical care; aside from age, the major determinant for outcome, hospital length of stay and the diagnosis of stroke have been shown to negatively i nflu- ence outcome [3]. In order to provide data that facilitate the assessment of long-term prognosis after neurocritical care we aimed to identify predisposing factors for a good f unctional recovery one year after treatment on a specialized neurocritical care unit. Materials and methods Patients and setting The present analysis was based on patients who were admitted to our 10-bed NICU (University Hospital Erlangen, Tertiary University H ospital) in 2006 and 2007. Given a separate neurosurgical ICU on the same * Correspondence: ines-christine.kiphuth@uk-erlangen.de 1 Department of Neurology, University of Erlangen, Schwabachanlage 6, 91054 Erlangen, Germany Kiphuth et al. Critical Care 2010, 14:R136 http://ccforum.com/content/14/4/R136 © 2010 Kiphuth et al.; licensee BioMed Central Ltd. This is an open access article distributed under the terms of the Creative Commons Attribution License (http://creativecomm ons.org/licenses/by/2.0), which permits unre stri cted use, distribution, and reproduction in any medium, provided the original work is properly cited. floor, patients with neurosurgical diseases such as trau- matic brain injury are not treated in our NICU. Be cause there is an additional 14-bed stroke and intermediate care unit, according to an institutional protocol, all patients admitted to our NICU must fulfill at least one of the following criteria: requiring mechanical ventila- tion, intravenous catecholamines, extraventricular or lumbar drainages, or have a Glasgow Coma Scale (GCS) below or equal to nine points. Furthermore, patients with evidence of vasospasms were also treated in our NICU. According to an inter-institutional protocol, patients with subarachnoid hemorrhage (SAH) who were treated endovascularly were admitted to our NICU, whereas SAH patients who were treated surgi- cally were admitted to the neurosurgical ICU. Likewise, patients with brain tumors at operable stages were trea- ted neurosurgically; those who were not operable, were treated neurologically. Seven-hundred and ninety-six neurological patients were admitted over the t wo-year perio d, representing our intention-to-treat cohort. Detailed data on this group are given in Figure 1 and Table 1. To more reli- ably analyze prediction of functional outcome we focussed on those patients who received specialized neurocritical care and excluded all patients who were set on do not treat (DNT) orders at admission. Patients who were se t on DNT ord ers were most severely affected (for example, signs of herniation on admission because of massive IC H) or they had severe co- morbid- ities and di d not consent t o invasive critical care thera- pies. These patients did not receive a ny treatm ent, except for intravenous fluids and morphine, and were only admitted to our neurocritical care unit because of already having been intubated and ventilated prior to hospital arrival. We determined apriorito focus on treated patients only and thus excluded patients wit h early DNT orders from our analysis of functional out- come after specialized neurocritical care. Contrary to this, patients who received any other therapeutic proce- dure are not referred to as DNT and remained in our analysis. Furthe rmore, we excluded all patients who were monitored on our NICU only temporarily either as outsourced patients from other ICUs or because of elective neuroradiologic procedure s; that is, pati ents who were monitored for only few hours until extubation after intracranial stenting or coiling (Figure 1). More- over, patients that were lost to follow-up at one year after discharge were excluded (n = 29; the baseline clin- ical data as well as in-hospital mortality of pat ients lost to follow-up did not vary significantly from the cohort Figure 1 Flowchart of patient selection. Kiphuth et al. Critical Care 2010, 14:R136 http://ccforum.com/content/14/4/R136 Page 2 of 8 analyzed (data not shown). Overall, 666 patients remained for final analysis and we refer to this group as the per protocol cohort. The institutional review board approved the study and consent was obtained in written or oral form from all patients or their relatives/legal guardians. Data collection and outcome analysis The parameters of age, sex, pre-admission mRS, length of hospital stay (LOS; in days), diagnosis, duration time of ventilation (LOV; in days) and modified TISS-28 (Therapeutic Intervent ion Scoring System) [4] wer e obtained by reviewing the patients’ hospital charts and institutional electronic databases. Mortality and func- tional outcome one year after discharge (as modified Rankin Scale (mRS)) were obtained by a mailed standar- dized questionnaire. In all cases i n which this question- naire did not return within six weeks, a standardized phone interview was conducted with the patients, or their closest relatives, respectively [5]. The telephone interviews were performed by one physician who was trained and certified for data collection on disability, quality of life, and the mRS. Given the heterogeneous patient population we grouped the patients with respect to their diagnoses (ischemic stroke, intracranial hemorrhage (ICH), subar- achnoid hemorrhage (SAH), epileptic seizures, menin- goencephalitis, Guillain-Barré syndrome (GBS) and Myasthenia gravis (MG), neurodegeneration/encephalo- pathy, inoperable cerebral neoplasm, and intoxication). Table 1 Demographic and clinical data All Ischemia ICH SAH Meningoencephalitis Epilepsy GBS/ MG Neurodeg/ Encephalopathy Neoplasm Intoxication Temporarily monitored n (%) 733 247 (33.7) 210 (27.4) 38 (5.2) 49 (6.7) 93 (12.7) 25 (3.4) 22 (3.0) 22 (3.0) 27 (3.7) 63 Age (median, range) 67 (18 to 95) 72 (21 to 93) 70 (35 to 95) 56 (19 to 84) 63 (27 to 85) 59 (18 to 93) 58 (23 to 78) 66 (23 to 90) 65 (39 to 78) 53 (29 to 78) 51 (33 to 68) Female sex (n, %) 350 (47.7) 111 (44.9 ) 100 (47.6) 20 (52.6) 26 (53.1) 48 (51.6) 14 (56) 14 (63.6) 8 (36.4) 9 (33.3) 26 (41.3) Pre-hospital mRS 0 to 2 n (%) 635 (86.6) 227 (91.9) 198 (94.3) 37 (97.4) 43 (87.8) 71 (76.3) 24 (96.0) 8 (36.4) 4 (18.2) 23 (85.2) 47 (74.6) Hospital length of stay in days (median, range) 4(0 to 87) 4(0to 57) 5(0 to 53) 4(0 to 63) 4(0to84) 1(0to 87) 6(0 to 57) 3 (1 to 50) 3 (0 to 17) 3 (0 to 19) 1(0to2) Mechanichal ventilation (n, %) 450 (61.4) 148 (59.9) 140 (66.7) 20 (52.6) 42 (85.7) 48 (51.6) 16 (64.0) 18 (81.8) 8 (36.4) 20 (74.1) 18 (28.6) Length of ventilation (d) (median, range) 3(0 to 83) 4(0to 43) 5(0 to 53) 1(0 to 60) 4(0to83) 0(0to 63) 6(0 to 49) 3 (0 to 50) 0 (0 to 13) 3 (0 to 14) 0(0to1) DNT (n, %) 38 (5.1) 9 (3.6) 22 (10.5) 3 (7.9) 0 0 0 2 (9.1) 2 (9.1) 0 0 Lost to follow-up (n, %) 29 (4.0) 6 (2.4) 5 (2.4) 1 (2.6) 2 (4.1) 7 (7.5) 1 (4) 2 (9.1) 3 (13.6) 2 (7.4) 16 (25.4) In-hospital mortality (n, %) 165 (22.5) 53 (21.5) 75 (35.7) 12 (31.6) 3 (6.1) 5 (5.4) 1 (4.0) 4 (18.2) 7 (31.8) 5 (18.5) 0 Mortality after 1 year (n, %) 292 (39.8) 100 (41.5) 121 (59.0) 18 (48.6) 6 (12.8) 14 (16.3) 1 (4.2) 11 (55.0) 15 (78.9) 6 (24.6) 1 (2.1) mRS 0 to 2 after 1 year (n, %) 208 (28.4) 33 (13.7) 40 (19.5) 11 (29.7) 28 (59.6) 57 (66.3) 16 (66.7) 5 (25.0) 1 (5.3) 17 (68.0) 38 (80.9) Demographic and clinical characteristics of all patients (n = 796) including a separate analysis for admission diagnosis (intention-to-treat cohort). Patients who were excluded for the per protocol-analysis are highlighted in bold. (PS: All patients monitored only temporarily (right column) are not included in the overall numbers (left column). Patients lost to follow up are not included in mortality and functional outcome after one year.) Abbreviations: ICH, intracranial hemorrhage; SAH, subarachnoid hemorrhage; GBS, Guillain-Barré syndrome; MG, myasthenia gravis; Neurodeg, neurodegenerative disease; n, number; d, days. Kiphuth et al. Critical Care 2010, 14:R136 http://ccforum.com/content/14/4/R136 Page 3 of 8 Functional outcome was defined as good (mRS 0 to 2; independent) or poor (mRS 3 to 6; dependent or dead). In addition, in-hospital mortality and the mortality rates one year after discharge were assessed. Statistical analysis Statistical analyses were performed using the SPSS 17.0 software pack age (SPSS Inc., Chicago, IL, USA). St atisti- cal tests wer e two-sided and the significance level was set at a = 0.05. The distribution of the data was assessed with the Kolmogorov-Smirnov te st. Continuous and categorical variables are expressed as mean and SD, as median a nd range, or as percentage, as appropri ate. Proportions between two groups were compared by using the c2 test, Fisher’s exact test or Mann-Whitney U test, as appropriate. One stepwise forward inclusion multivariate logistic regression model was calculated for prediction of good functional outcome one year after neurocritical care including those parameters that showed at least a trend when being tested univariately (P < 0.1). Interaction terms did not reveal significant interaction between the variables. In the univariate and multivariate analyses, the parameters LOS and LOV were calculated as dichto- mized variables (according to their median); however, LOV was also calculated as a continuous variable (that is, increasing days) in the univariate analysis. The modi- fied TISS-28 score is given as value per day and was categorized (< 21, 21 to 40, > 4 0), as described pre- viously [3]. Results Analysis of all patients admitted to the neurocritical care unit (Intention-to-treat population) The demographic and clinical characteristics of all 796 patients are given in Table 1. The analysis according to admission diagnoses revealed that nearly 60% of all patients suffered fro m stroke (ischemic stroke: n = 247; 31% and ICH: n = 210; 26%). Patients were diagnosed with SAH in 5% (n = 38), epileptic seizures in 12% (n = 93), meningoencephalitis in 6% (n = 49), Guillai n-Barré- Syndrome and myasthenia gravis in 3% (n =25),neuro- degenerative diseases and encephalopathy in 3% (n = 22), cerebral neoplasm in 3% (n = 22), and intoxications in 3% (n = 27). The remaining 63 pati ents were patients outsourced from general ICUs due to space limitations as well as patients temporarily monitored after neurora- diological procedures. The median length of stay was four days (0 to 87 days). The median length of ventila- tion was three days (0 to 83 days). The median modified TISS-28 score on Day 1 was 38 (18 to 71), the median TISS-28 score at discharge was 19 (15 to 43). When only focussing on treated patients, the in-hospital mor- tality amounted to 22.5%, and mortality rate after one year was 39.8%. Including patients who were set on DNT orde rs, the in-hospital mortality rate amounted to 27.7%, and the one-year mortality rate was 45.0%. For more detailed data please refer to Table 1. Analysis of patients receiving specialized neurocritical care (per protocol population) Figure 2 shows data on in-hospital mortality, mortality after one year, and functional outcome one year after neurocritical car e. Overall in-hospital mortality was 19.1%, and overall mortality after one year was 38.1%. Proportional to the patient numbers, ischemic stroke, ICH, SAH, cerebral neoplasm, and neurodegenerative diseases revealed the highest frequency of in-hospital and long-term mortalities compared to the remaining patients (P < 0.01). Overall, 31.2% o f the per-protocol population achieved a favorable functional long-term outcome. Good functional outcome was achieved signifi- cantly more often in patients with meningoencephalitis, epilepsy, GBS/MG, and intoxication (P < 0.01). Prediction of good functional long-term outcome after neurocritical care The logistic regression analysis of all patients who rec eive d specialized neurocritical care for pr ediction of a good functional outcome one year after discharge is shown in Table 2. After adjustment, the diseases GBS and MG were independently related to a good long-term outcome, whereas age, LOV, and TISS-28 score on Day 1 as well as the diagnoses ICH and cerebral neoplasm were predisposing factors for an unfavorable outcome. Discussion First of all it has to be noted that neurocritical care medicine deals with severely ill patients with a highly constricted c apability of regeneration of neurons of the central nervous sy stem. Hence, neurological syndromes due to neurovascular and inflammatory causes, which represent the majority in this study and result in the necessity of intensive care only show a limited capacity of complete recovery, whereas diseases without affection of neurons, that is, due to autoimmune causes, recover y may not be limited [6 ]. Nonetheless, specialized neuro- critical care is justified as a number of specific treatment regimens have emerged over the past years. Examples for specific neurocritical care therapies include hemicra- niectomy for treatment of space-occupying large cere- bral infarctions [7] as well as continuous intracranial pressure and oxygen monitoring with intraparenchymal probes [8]. Patients with b asilar artery and carotid artery-T occlus ion may receive interventional treatment with a combined approach of intravenous and intraar- terial thrombolytics [9] with or without use of r ecanali- sation devices [10]. ICH patients with intraventricular Kiphuth et al. Critical Care 2010, 14:R136 http://ccforum.com/content/14/4/R136 Page 4 of 8 hemorrhage may undergo special treatment with extra- ventricular d rainages, intraventricular thrombolysis and lumbar drainage for communicating hydrocephalus [11-13]. Both ischemic and hemorrhagic stroke can be treated with endovascular cooling to reduce edema for- mation and to reduce further impairment of so far healthy brain tissue [14]. Furthermore, patients with GBS are treated with plasma exchange, intravenous immunoglobulins, ventilation and external pacemakers for severe autonomic dysfunction [15,16]. However, the benefit of some of these neurointensive procedures has not been shown in large randomized trials. Furthermore, admittance to a NICU has been shown to reduce mor- tality and LOS and improve functional outcome as com- pared to a general ICU [2,17-19]. These benefits are most likely multifactorial and may b e related to elevated attention in a neurocritical care setting to factors like reduced alertness that may result in secondary dete- rioration as well as neuroprotective measures such as normothermia, strict blood pressure management and management of cerebral edema formation. In the present study we investigated the long-term out- come of treated patients receiving specialized neurocritical care and identified predisposing factors for a good func- tional outcome. As a key finding, overall outcome one year after treatment was fairly positive with 28.4% showing a good functional outcome of a mRS ≤ 2. Mortality Mortality in criti cal care medicine is naturall y high. Patients with hepatic e ncephalopathy (median age 58 years) showed a mortality rate one year after an ICU stay that amounted to 5 4% [20]. In critically ill surgical patients (mean age 65 years) survival one year after ICU discharge was reported to be 33% [21]. A systematic review of s tudies on general ICU patients showed a one year mortality between 26 and 63% (n = 5,725, mean age 55 years) [22]. C ontrary, there are only limited data on outcome and mortality of NICU patients. The only available study that investigated a patient collective comparable to ours, reported a mortality rate of 47% after a mean follow-up time of 2.7 years [3]. In our cohort, overall mortality one year af ter NICU stay was as high as 39.8%. These rates were mainly driven by stroke patients and those with other diseases with high mortality rates such as neurodegenerative diseases, ence- phalopathy and inoperable cerebral neoplasms [23]. Functional outcome and outcome-predicting diseases Regarding the functional outcome of the surviving patients the parameter age is the major determinant of outcome, as described previously [3]. However, com- pared t o many non-neurological diseases, age in neuro- logical patients is not a fixed determinant for poor outcome but a rather relative parameter that has to be Figure 2 Functional status after one year, in-hospital mortality and mortality after one year for all patients treat ed per protocol (n = 666). Kiphuth et al. Critical Care 2010, 14:R136 http://ccforum.com/content/14/4/R136 Page 5 of 8 put into perspective to the underlying disease, for exam- ple, reversible inflammatory disease (GBS) versus irre- versible brain tissue damage by stroke or ICH [3,6]. Several therapies applied in neurocritical care are linked to the age of patients. For instance, a 75-year-old patient with malignant middle cerebral artery infarction will not undergo hemicraniectomy because outcome likely will be poor with or without decompressive surgery, ho w- ever, this is going to be investigated in the DESTINY 2 trial (ISRCTN21702227). In contrast, a patient with GBS of the same age will surely receive all possible critical care treatment. Given (i) an overall younger age of the analyzed patients of general and surgical ICU’sascom- pared to our study (that is, approximately 60 years [20-22] versus 67 years), and (ii) the age-associated co- morbidity of our patients, the functional outcome data presented here are respectable. In addition, functional outcome was significantly related to the severity of ill- ness on Day 1 as reflected by the TISS-28, indicating that the severity of disease at admission predicts func- tional outcome one year after discharge. Therefore, the initial TISS-28 may be used to help decide whether invasive therapeutic procedures such as hemicraniect- omy in malig nant middle cerebral arter y infarction ought to be carried out. The admission diagnoses of GBS and myasthenia gravis were related to good functional outcome one year after discharge. Compared to patients with a benign dis- ease course, patients with rapidly progress ive neuromus- cular weakness, dysautonomia and those requiring ventilation, thus requiring NICU admission, are known to have a less favorable outcome [24-26]. However, compared to irreversible central nervous system dis- eases, patients with GBS and MG who require neurocri- tical care tend to have a better functional outcome after one year. This is mainly based on the potentially reversi- ble character of these diseases and the substantial pro- gress in therapy within the last decades [27,28]. In contrast, patients with seizures did not reach statistical trends towards a good outcome. The finding that not all of the potentially reversible diseases showed a good out- come is most likely related to underlying severe co-mor- bidity [29,30], for example, symptomatic seizures after a stroke with a mortality of nearly 20% [31,32]. The diagnosis of ICH, often associated with intraven- tricular hemorrhage, was associated with both the Table 2 Predictors for functional outcome Good outcome (mRS ≤ 2) Exp(Coef) 95% CI P-value Univariate Age 0.834 0.794 to 0.872 < 0.0001 SEX (female) 1.265 0.554 to 1.864 0.57645 Hospital LOS 0.759 0.281 to 0.866 0.04397 Length of ventilation 0.410 0.113 to 0.641 0.01202 Length of ventilation (per increasing day) 0.974 0.913 to 1.061 0.09441 TISS-28 on Day 1 < 21 2.746 1.935 to 4.391 0.00666 20 to 40 1.273 0.764 to 1.812 0.21932 > 40 0.715 0.621 to 0.944 0.00181 TISS-28 at discharge < 21 2.187 1.453 to 3.812 0.01215 20 to 40 1.234 0.218 to 2.187 0.23156 > 40 0.711 0.451 to 0.857 0.00017 Ischemia 0.724 0.485 to 0.932 0.04275 ICH 0.743 0.573 to 0.935 0.02046 SAH 0.636 0.273 to 1.198 0.63532 Meningoencephalitis 1.412 0.996 to 3.238 0.12432 Epilepsy 1.433 0.233 to 2.346 0.73255 GBS/MG 3.623 1.124 to 13.327 0.00145 Neurodeg./Encephalopathy 0.680 0.274 to 1.019 0.05723 Neoplasm 0.692 0.371 to 0.856 0.00039 Intoxication 5.809 1.832 to 7.483 0.03881 Multivariate Age 0.786 0.435 to 0.823 0.00245 Hospital LOS 0.509 0.272 to 1.279 0.17647 Length of ventilation 0.681 0.475 to 0.912 0.00354 TISS-28 on Day 1 > 40 0.815 0.578 to 0.931 0.00187 Ischemia 0.345 0.245 to 1.101 0.11458 ICH 0.643 0.218 to 0.877 0.03874 GBS/MG 2.215 2.006 TO 3.214 0.03329 Neurodeg./Encephalopathy 0.705 0.297 to 1.354 0.15478 Neoplasm 0.687 0.354 to 0.934 0.04875 Intoxication 1.399 0.964 to 2.648 0.27261 Univariate and multivariate regression analysis for parameters predic ting a good func tional outcome (mRS 0 to 2) one year after neurocritical care. Analysis of all patients receiving specialized neurocritical care (n = 666). Parameters that reached significance ( P < 0.05) are expressed in bold. Parameters that showed a statistical trend (P < 0.1) in the univariate analysis are expressed in italics. Abbreviations: CI, confidence interval; LOS, length of stay; ICH, intracranial hemorrhage; SAH, subarachnoid hemorrhage; GBS, Guillain-Barré syndrome; MG, myasthenia gravis; Neurodeg, neurodegenerative disease Kiphuth et al. Critical Care 2010, 14:R136 http://ccforum.com/content/14/4/R136 Page 6 of 8 highest in-hospital mortalityandmortalityafterone year. This finding was in line with previous reports [3] and indicates that, while some patients with ICH improve clinically [33], the overall functional status of patients with this diagnosis deteriorates. ICH leads to substantial disabil ity itself, causing reduced leve ls of consciousness, mechanical ventilation and extended ICU stay which again cause further complications, high early mortality and generally poor functional outcome [34,35]. Length of ventilation The LOV was independently predictive for a negative outcome. This feature has not yet been described. The length of hospital stay (LOS) showed a significant asso- ciation with outcome in the univariate analysis but did not, as shown before [1,3,36], independently predict poor outcome and hence LOV, rather than LOS may serve as a surrogate marker for disease severity. This is most likely related to the fact that patients who required prolonged ventilation, per definition, had a l onger LOS, whereas patients with prolonged LOS were not always mechanically ventilated and the LOS was occasionally affected by the availability of beds on other wards and rehabilitation centres. This aspect, that LOV rather than LOS reflects disease severity, might be focussed on in futurestudiesasitappearslikelythattherearediffer- ences regarding the specific diseases. Limitations The data presented have certain shortcomings, mainly the retrospective design of the study and the loss of some patients to follow-up analysis. Moreover, changes in staffing of our ICU might have altered treatment stra- tegies and led to changes i n outcomes. Outcome was assessed one year after neurocritical care, however, mailed questionnaires filled-out by patients or their rela- tives have an inherent predisposition for inaccuracy with respect to t he validity of mRS estimation [37,38]. Further criticism might arise due t o the rather rigorous cut-off rate we defined for outcome definition (that is, mRS ≤ 2 f or good outcome). We aimed to identify only those patients who were functional ly independ ent with- out requiring assistance for their daily activities. Other neurological studies which referred to the functional outcome as a primary endpoint have not necessarily used the same c ut-off points [3,6]. Moreover, other important parameters possibly influencing outcome, such as GCS on admission or the requirement of intra- venous catecholamines, were not sufficiently assessable in this retrospective analysis. Finally, the impact of reha- bilitation was not assessed which may have influenced the results on functional outcome after neurocritical care. Conclusions Although this appears counterintuitive, functional out- come and mortality of patients treated in specialized NICU units compare favourably with those in other intensive care fields. This highlig hts the impact of spe- cialized neurocritical care proce dures. The data pre- sented here suggest that age, admissi on diagnosis, TISS- 28 on Day 1, and length of ventilation are important independent predictors for outcome in neurocritical care patients. However, more disease-specific prognostic information on clinical course and functional outcome are needed to guide neurocritical care physicians in their identification process of patients who benefit from neurocritical care, and to possibly confine extended neurocritical treatment in certain situations, respectively. Key messages • In neurocritical care, disease-specific prognostic information on clinical course and functional out- come are needed to guide neurocritical care physi- cians in their identification process of patients who benefit from neurocritical care. • In this large, consecutive neurointensive care patient cohort, the diseases GBS and MG were inde- pendently related to a good long-term outcome, whereas older age and increased length of ventilation as well as the diagnoses ICH and cere bral neoplasm were predisposing factors for an unfavorable outcome. Abbreviations DNT: do not treat; GBS: Guillain-Barré syndrome; GCS: Glasgow Coma Scale; ICH: intracranial hemorrhage; ICU: intensive care unit; LOS: length of hospital stay; LOV: duration time of ventilation; MG: myasthenia gravis; mRS: modified Rankin Scale; NICU: neurocritical care units; SAH: subarachnoid hemorrhage; TISS: Therapeutic Intervention Scoring System. Acknowledgements We would like to thank Dr. E. Pauli (Department of Neurology, University of Erlangen, Germany) for helping with the statistics. Author details 1 Department of Neurology, University of Erlangen, Schwabachanlage 6, 91054 Erlangen, Germany. 2 Department of Neuroradiology, University of Erlangen, Schwabachanlage 6, 91054 Erlangen, Germany. Authors’ contributions ICK, SS and HBH designed the study and wrote the manuscript. PDS, MK and HBH performed substantial data extraction of institutional databases. JB, HL, SK and ICK reviewed the medical charts and obtained laboratory and radiological data. 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Banks JL, Marotta CA: Outcomes validity and reliability of the modified Rankin scale: implications for stroke clinical trials: a literature review and synthesis. Stroke 2007, 38:1091-1096. 38. Huybrechts KF, Caro JJ: The Barthel Index and modified Rankin Scale as prognostic tools for long-term outcomes after stroke: a qualitative review of the literature. Curr Med Res Opin 2007, 23:1627-1636. doi:10.1186/cc9192 Cite this article as: Kiphuth et al.: Predictors for good functional outcome after neurocritical care. Critical Care 2010 14:R136. Kiphuth et al. Critical Care 2010, 14:R136 http://ccforum.com/content/14/4/R136 Page 8 of 8 . long-term outcome after neurocritical care The logistic regression analysis of all patients who rec eive d specialized neurocritical care for pr ediction of a good functional outcome one year after. 1. Analysis of patients receiving specialized neurocritical care (per protocol population) Figure 2 shows data on in-hospital mortality, mortality after one year, and functional outcome one year after neurocritical. are only limited data on the long-term outcome of patients receiving specialized neurocritical care. In this study we analyzed survival, long-term mortality and functional outcome after neurocritical